Alana reached the safety of home, threw the car keys down, and collapsed on the couch, exhausted. What a difficult day! She who hated going out at all had had to go to three whole things outside the house: unbearable! First she had to be at the school for parent-teacher meetings, and although her two primary-school-age daughters were doing well, it was draining to have to meet the teachers and focus on all the school program information. Afterwards, she had had to negotiate busy central-city traffic and parking for a medical appointment. Her results showed that the lump was benign, but she couldn’t help wondering if they had missed something; after all, many cases of cancer came to be terminal because of errors at the diagnostic stage… If all that weren’t bad enough, her trip to the local mall for groceries and a few other errands had ended badly.

Already agitated when entering the mall, Alana had gone into a panic attack which was noticed by fellow shoppers. There was a huge commotion as people rallied around to help; the mall’s first aid staff called an ambulance before the attack subsided. Alana was mortified to be the centre of so much unwelcome (if well-meaning) attention. At home now, she broke down and cried as she realised how ineffectively she was doing life.

One week later, she found herself in the offices of Hayley, a psychotherapist. “I’m not sure what I’m doing here,” she confessed, her face reddening. “You see, I’ve had some counselling before. It just didn’t work for me: endless forms to fill for ‘homework’ about what I’m thinking and always being forced to re-traumatise myself in the very situations that make me so anxious. I don’t know.” Alana looked pleadingly at Hayley. “I am chronically tired, sleeping poorly, and dearly want to get rid of this anxiety. It is so crippling; I can’t even take on a job, but I am really uncertain as to whether therapy – or anything – can help me.”

Alana, sadly, is not unique in her pain. Anxiety disorders are the most common mental illness in the United States, affecting 40 million adults age 18 and older (18 percent of the U.S. population) (ADAA, 2014). The percentage is similar in Australia, with 14.4 percent of Australians being affected by an anxiety disorder in any 12 month period (Mindframe, 2012). Even though only one-third of those in both countries seek treatment for the disorder, anxiety carries a huge disease burden, costing the United States more than $42 billion a year, almost one-third of the country’s total mental health bill (ADAA, 2014). Similarly in Australia, anxiety and depressive disorders are the third leading cause of disability burden, accounting for about 27 percent of the years lost to disability (Mindframe, 2012).

Yet even among the one-third of sufferers who have sought treatment, many, like Alana, have come away disappointed – and still anxious. If you were Hayley, what sort of approach would you want to use with a client like Alana? Would it help her move past the ambivalence and uncertainty she expresses above toward commitment to following a treatment plan? Would your recommended approach even have a means of dealing with such resistance to change? Motivational interviewing is a therapeutic approach gaining wide popularity in mental health practitioner circles as a respectful, client-centred means of working with clients to help them resolve ambivalence and build resolve: either to make change – the obvious endpoint of most therapy – or to maintain the status quo, if that is determined to be preferable.

What is it MI treats when anxiety is the issue?

To ensure that we’re all on the same page here, let us briefly define anxiety and anxiety disorders.

Anxiety is known experientially to some degree by nearly everyone at one time or another, anxiety is said to be: “A multidimensional emotional state manifested as a somatic, experiential, and interpersonal phenomenon; a feeling of uneasiness, apprehension, or dread. These feelings may be accompanied by symptoms such as breathlessness, a choking sensation, palpitations, restlessness, muscular tension, tightness in the chest, giddiness, trembling, and flushing, which are produced by the action of the autonomic nervous system, especially the sympathetic part of it” (Farlex, 2015a).

Anxiety disorders are: “A group of mental disturbances characterised by anxiety as a central or core symptom. Although anxiety is a commonplace experience, not everyone who experiences it has an anxiety disorder. Anxiety is associated with a wide range of physical illnesses, medication side effects, and other psychiatric disorders” (Farlex, 2015b)

The chief anxiety disorders which are included in the DSM-5 are grouped into three sections or chapters and include, in descending order of prevalence:

• Specific phobias or fear of certain objects or situations, such as spiders, heights, or flying: about 8.7 percent of the population
• Social Anxiety Disorder, or social phobia, fear of humiliation in social or public situations: 6.8 percent
• Post-Traumatic Stress Disorder and other trauma-induced anxiety disorders (now in their own chapter in the DSM-5), when someone persistently re-experiences a traumatic event, has distress associated with reminders of the event, and emotional detachment: 3.5 percent
• Generalised Anxiety Disorder, excessive uncontrollable worry in a number of areas, such as health, finances, work performance, or others’ wellbeing: 3.1 percent
• Agoraphobia/Panic Disorder/Panic attacks, a fear of being unable to escape or of being alone in the event of a panic attack (for agoraphobia), or sudden escalation of multiple somatic fear symptoms, such as shortness of breath or racing heart (for panic attacks); recurrence of these unexpectedly constitutes panic disorder: 2.7 percent
• Obsessive-Compulsive Disorder (OCD) and other obsessive or compulsive anxiety disorders (now in their own chapter in the DSM-5), comprising recurrent and intrusive thoughts, images, and impulses, such as fears of contamination and/or repetitive actions aimed at reducing anxiety or neutralising obsessive thoughts: 1 percent of the population (ADAA, 2014; Westra, 2012).

The problem with anxiety

There are few among us who have not experienced anxiety: the sweaty palms as you are led into the interview room for the BIG JOB you really want; the racing heart as you stand up to recite your wedding vows; or the jelly-like knees and adrenalin kick as you prepare to do your first dive. All of these and many more situations in life trigger the stress response in us that naturally creates moments of anxiety. Most of us, however, do not have anxiety disorders. We have the normal experience of anxiety in a situation that is novel or where there is potential or actual risk, we handle the situation, and we go back to feeling normal.

For those with anxiety disorders, life is not so simple. Anxiety is present in one manifestation or other in many, if not most, life situations. Even if there is not an immediate, objectively observed threat, the person with an anxiety condition may be creating anxiety by ruminating over terrible possibilities which he or she is certain are soon to occur and simultaneously working out how to avoid the dreaded events. It is one thing for us to state, as above, how much – actually how little – of the population (as a percent of the total) is suffering from a given type of anxiety. It is quite another to appreciate the impact of the disorder on a person’s life or the total cost of that disorder in terms of human suffering.

Even though health professionals have heard it for years from their clients in myriad variations, studies now assert that anxiety, in all of its shades, is largely responsible for impairment in educational and career development, family life, and relationships, to say nothing of the difficulty achieving a sense of joy and contentment in life. Health professionals are keenly aware of the extra space in emergency departments and general practice consulting rooms that anxious patients take up through their excessive worry (Mendlowicz and Stein, 2000, in Westra, 2012), as people with an anxiety disorder are three to five times more likely to be hospitalised for psychiatric disorders than those who do not suffer from anxiety disorders. In the United States, nearly $23 billion is spent annually for health care services by anxiety-ridden patients seeking relief from symptoms mimicking physical illnesses (ADAA, 2014). And the symptoms persist, usually worsening, if they are not treated, as such clients limp along, chronically unhappy and often depressed.

So it makes sense to treat anxiety, and it is entirely treatable. Yet achieving freedom from anxiety seems to be counterintuitive in many ways. That is, it seems quite reasonable that if someone like Alana were to appear in our rooms, we would be able to gently “talk some sense” into her, by helping her to see how illogical her many fears were, and how it makes more sense to face her fears (in small, gradually increasing doses) in order to move past them. It seems totally sensible that we might suggest a program of identifying her fearful thoughts, getting her to replace them with less maladaptive cognitions, all the while having her affirm her competence and freedom from fear as she behaves in new ways. The support we could help her set up for this could also improve her relationships, strained by crippling fears. Surely, the discomfort and resultant exhaustion of being in dread of everyday situations (such as encounters with teachers, traffic, and mall crowds) is awful enough that a sufferer would be motivated to follow whatever treatment plan their health professional suggested in order to feel better: surely!

Unfortunately, the counterintuitive truth we refer to is that, even those who are highly motivated to succeed – like Alana – experience a significant amount of ambivalence at making a change (from a life full of anxiety to one without it). Even otherwise diligent, treatment-compliant types like Alana still may experience that action-oriented therapies, such as Cognitive-Behavioural Therapy or CBT, do not meet their therapeutic needs in the process of attempting change; this is so because of the customary presence of ambivalence.

Why we might use MI to treat anxiety

Westra notes that ambivalence to change is extremely common, even among those who have committed to treatment. She claims that up to two-thirds of individuals who have decided to enter a treatment program for mental health problems can be classified as being in either the pre-contemplation stage (not yet actively considering change) or the contemplation stage of change (considering change, but conflicted about it) (Westra, 2012). Such individuals, in their uncertainty or indecision about changing, are unlikely to use change-oriented strategies, like the CBT approach. Rather, the early stages of change are characterised by alternating movement toward and away from the contemplated change. Such a “two-steps-forward-one-step-back” journey is a normal response to change, because, while people desire change, they also fear it. Continuing to do things “the way I’ve always done it” is seductive; it is familiar and sometimes rewarding, as the client sees that maintaining the status quo “sort of” or “almost” or “sometimes” works and changing has big costs.

Moreover, research has shown that a significant proportion of clients (up to 94 percent of OCD-diagnosed clients in one study) have concerns about the treatment itself (Purdon, Rowa, & Antony, 2004). Clients with anxiety, particularly, can convince themselves that how things are now is “not that bad”. Even the thought of engaging change behaviours to reduce anxiety can be anxiety-producing! A treatment failure might make the individual feel even more hopeless. A treatment success, conversely, will put pressure on the person to always perform at a higher, non-anxious level (Kushna and Sher, 1989).

In the context of ambivalence, clinician attempts to logically talk people out of anxiety, forcing confrontation with their worries and fears (including with exposure), has been shown to increase, not decrease, clients’ capacity for change (Moyers, Christopher, Houck, Tonigan, & Amrhein, 2007). As practitioners, we might like to call this typical client response illogical or even pathological; at the very least, it shows a strong effort by clients to self-protect. Motivational interviewing therapists contend that to help people change we need to not only understand this self-protectiveness, but also respect and work with it.

Resistance in therapy

Engle and Arkowitz (2006) assert that a lot of what clinicians tend to see as resistance is actually clients dealing with ambivalence. It explains why CBT and similar action-oriented practitioners chronically complain of low levels of compliance with homework and other treatment procedures. Kazantzis, Lampropoulos, & Deane (2005) have identified that in surveys of CBT-oriented practices, failing to do the assigned task is a commonplace occurrence, with only a minority of clients actually being fully compliant. Even more, resistance to therapist direction has been identified as a strong predictor of both subsequent engagement with the tasks of treatment (Jungbluth & Shirk, 2009) and also outcome (Aviram & Westra, 2011).

A client requires a fairly high level of motivation in order to be able to implement treatment actions toward change. Limited engagement with treatment tends to be responsible for limited response rates to treatments. Even though CBT has well-established efficacy for the treatment of anxiety and depression, there is still a sizable minority of clients for whom treatment is ineffective. A large study of depressed adolescents, for example, showed that the response rate at termination of treatment for subjects receiving CBT was 48%; this rose to 65% six weeks later (TADS, 2007), meaning that at best one in three clients was still unresponsive. Similarly with anxiety, Westen and Morrison (2001) have shown that a substantial proportion of clients does not engage or respond appropriately, despite documented efficacy and manualised procedures.

The core value of MI is that, by working with client ambivalence – as demonstrated in the person’s resistance – and respecting the client’s autonomy and capacity to choose change if and when it feels right, MI achieves high levels of client engagement, which creates high levels of outcomes.

This article was adapted from the upcoming “Treating Anxiety with Motivational Interviewing” Mental Health Academy CPD course. Learn more at www.mentalhealthacademy.com.au.

Further reading

• Motivational interviewing: The definitions, the spirit, and what it is not
• Principles and techniques of Motivational Interviewing

References

• Anxiety and Depression Association of America (ADAA). (2014). Facts and statistics. Anxiety and Depression Association of America. Retrieved on 21 January, 2015, from: hyperlink.
• Aviram, A. & Westra, H.A. (2011). The impact of motivational interviewing on resistance in cognitive-behavioral therapy for generalized anxiety disorder. Psychotherapy Research, 21(6), 698-708.
• Engle, D. & Arkowitz, H. (2006). Ambivalence in psychotherapy: Facilitating readiness to change. New York: Guilford Press.
• Farlex. (2015a). Definition of anxiety: Anxiety. Free Dictionary. Farlex, Inc. Retrieved on 21 January, 2015, from: hyperlink.
• Farlex. (2015b). Definition of anxiety: Anxiety disorders. Free Dictionary. Farlex, Inc. Retrieved on 21 January, 2015, from: hyperlink.
• Jungbluth, N.J. & Shirk, S.R. (2009). Therapist strategies for building client involvement in cognitive-behavioral therapy for adolescent depression. Journal of Consulting and Clinical Psychology, 77, 1179-1184.
• Kazantzis, N., Lampropoulos, G.K., & Deane, F.P. (2005). A national survey of practicing psychologists’ use and attitudes toward homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73(4), 742-748.
• Kushna, M.G. & Sher, K.J. (1989). Fear of psychological treatment and its role in mental health treatment avoidance. Professional Psychology: Research and Practice, 20, 251-257.
• Mindframe. (2012). Facts and stats about mental illness in Australia. National Media Institute. Retrieved on 21 January, 2015, from: hyperlink.
• Moyers, T.B., Martin, T., Christopher, P.J., Houck, J.M., Tonigan, J.S., & Amrhein, P.C. (2007). Client language as a mediator of motivational interviewing efficacy: Where is the evidence? Alcoholism: Clinical and Experimental Research, 31(S3), 40S-47S.
• Purdon, C., Rowa, K., & Antony, M.M. (2004). Treatment fears in individuals awaiting treatment of OCD. Paper presented at the meeting of the Association for Advancement of Behavior Therapy, New Orleans, LA.
• TADS Team. (2007). The Treatment for Adolescents with Depression Study (TADS): Long-term effectiveness and safety outcomes. Archives of General Psychiatry, 64, 1132-1143.
• Westen, D. & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 69(6), 875-899.
• Westra, H.A. (2012). Motivational interviewing in the treatment of anxiety. New York: Guilford Press.